A feasibility, randomised controlled trial of Club Connect: a group-based healthy brain ageing cognitive training program for older adults with major depression within an older people's mental health service.

BACKGROUND: Using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, we outline steps taken to implement an evidence-based cognitive training program, Club Connect, in older adults with major depressive disorder in an Older People's Mental Health Service in Sydney, Australia. The primary aim was to explore feasibility (or 'reach'), tolerability (or 'implementation'), and acceptability (or 'adoption'). The secondary aim was to explore the most sensitive clinical outcomes and measurement tools (i.e. 'effectiveness') to inform a formal randomised controlled trial, and to explore the healthcare resources used (i.e. costs) to assist decision-making by health care managers and policy-makers in relation to future resource allocation. METHODS: Using a single blinded feasibility design, 40 participants (mean age: 76.13 years, SD: 7.45, range: 65-95 years) were randomised to either (a) Club Connect, a 10-week group-based multifaceted program, comprising psychoeducation and computer-based cognitive training, or (b) a waitlist control group. RESULTS: Implementing group-based cognitive training within a clinical setting was feasible, well tolerated and accepted by participants. Further, cognitive training, in comparison to the waiting list control, was associated with moderate to very large effect size improvements in depression, stress and inhibition (ηp2 = 0.115-0.209). We also found moderate effect size improvements on measures of daily functioning, wellbeing and cognitive flexibility. Small effect size improvements for other cognitive and psychosocial outcomes were also observed. The average cost per person participating in in the intervention was AU$607.50. CONCLUSIONS: Our findings support the feasibility of implementing group-based cognitive training into a specialised clinical (public health) setting. This trial was registered on the Australian and New Zealand Clinical Trial Registry (ACTRN12619000195156, 12/02/2019).

A Systematic Review and Meta-Analysis of Cognitive Training in Adults with Major Depressive Disorder.

Major Depressive Disorder (MDD) is common and disabling, and is linked to functional impairment and increased mortality. While current treatments for MDD are moderately effective, ultimately, up to one third of patients do not achieve full remission. Interestingly, while affective symptoms of major depression typically resolve with the depressive episode, cognitive impairment frequently persists, and has been identified as one of the most prominent predictors of illness recurrence. Additionally, MDD is well-recognised as a key risk factor for further cognitive decline and dementia. Yet, available treatments for MDD do not typically address cognitive impairment. Cognitive training, represents a promising and novel therapeutic intervention in this regard. This review systematically identified and evaluated the evidence for cognitive training in adults with MDD. Following PRISMA guidelines, eligible studies were selected according to pre-defined criteria delineating our target population (adults with clinically defined MDD), parameters for cognitive training interventions (computer-or strategy-based, clinician-facilitated), and study design (controlled trials including pre-post cognitive and psychological or functional outcome data). Of 448 studies identified, nine studies met inclusion criteria. These studies were evaluated for methodological quality and risk of bias. Despite heterogeneity, qualitative and meta-analytic synthesis of study findings revealed significant improvements in cognitive and affective outcomes following cognitive training, with moderate pooled effect sizes. Unfortunately, very few studies investigated 'far transfer' to broader domains of everyday functioning. Overall, given the strong evidence for the efficacy and value of cognitive training in this context, cognitive training should be considered as a primary therapeutic intervention in the treatment of MDD.

Episodic memory in depression: the unique contribution of the anterior caudate and hippocampus.

BACKGROUND: Learning and memory impairments in older adults with depression are linked to hippocampal atrophy. However, other subcortical regions may also be contributing to these deficits. We aimed to examine whether anterior caudate nucleus volume is significantly reduced in older adults with depression compared to controls; whether anterior caudate volume is associated with performance on tasks of episodic learning and memory, and if so, whether this association is independent of the effects of the hippocampus. METHOD: Eighty-four health-seeking participants meeting criteria for lifetime major depressive disorder (mean age = 64.2, s.d. = 9.1 years) and 27 never-depressed control participants (mean age = 63.9, s.d. = 8.0 years) underwent neuropsychological assessment including verbal episodic memory tests [Rey Auditory Verbal Learning Test and Logical Memory (WMS-III)]. Magnetic resonance imaging was conducted, from which subregions of the caudate nucleus were manually demarcated bilaterally and hippocampal volume was calculated using semi-automated methods. RESULTS: Depressed subjects had smaller right anterior caudate (RAC) (t = 2.3, p = 0.026) and poorer memory compared to controls (t = 2.5, p < 0.001). For depressed subjects only, smaller RAC was associated with poorer verbal memory (r = 0.3, p = 0.003) and older age (r = -0.46, p < 0.001). Multivariable regression showed that the RAC and hippocampus volume uniquely accounted for 5% and 3% of the variance in memory, respectively (ß = 0.25, t = 2.16, p = 0.033; ß = 0.19, t = 1.71, p = 0.091). CONCLUSIONS: In older people with depression, the anterior caudate nucleus and the hippocampus play independent roles in mediating memory. While future studies examining this structure should include larger sample sizes and adjust for multiple comparisons, these findings support the critical role of the striatum in depression.

Managing depression across the life cycle: new strategies for clinicians and their patients.

Depression is the leading cause of non-fatal disease burden in Australia. Recently, increasing public recognition, together with the development of more integrated medical and psychological healthcare services has resulted in significant improvements. New pathophysiological models incorporate structural brain changes with established changes in neurotransmitter function. Further, recognition of predisposing factors and the salience of differential ages of onset have led to more pragmatic diagnostic systems. There is an ongoing need to promote early recognition, better information to inform treatment choices and more comprehensive treatment programmes that incorporate behavioural and lifestyle factors in addition to the wide range of pharmacological therapies that are now available.

Death of dopaminergic neurones in the rat substantia nigra can be induced by damage to globus pallidus.

Parkinson's disease is a debilitating disorder that results from the death of dopaminergic neurones in the substantia nigra. Subthalamic nucleus neurones use glutamate as their neurotransmitter and send excitatory projections to the substantia nigra. Changes in both the mean firing rate and firing pattern of neurones of the subthalamic nucleus have been found in patients with this disease. This has led to the suggestion that hyperactivity of the subthalamic nucleus may be involved in the pathology of the dopaminergic neurones. Subthalamic nucleus lesions or treatment with glutamatergic antagonists can be neuroprotective in animal models of Parkinson's disease but until now there has been no direct evidence that hyperactivity of subthalamic nucleus neurones can lead to downstream cell death. Here we show that lesions of the rat globus pallidus (a treatment that has been shown to increase subthalamic nucleus neuronal activity) result in a significant reduction of the number of dopaminergic neurones in the substantia nigra.

Corticofugal axons from adjacent 'barrel' columns of rat somatosensory cortex: cortical and thalamic terminal patterns.

The cortical representations of the vibrissae of the rat form a matrix in which each whisker has its own area of cortex, called a 'barrel'. The afferent pathways from the periphery travel first to the trigeminal nuclei and thence via the ventroposteromedial thalamus (VPM) to the cortical barrels have been described in detail. We have studied the output from barrels by filling adjacent areas of the primary somatosensory cortex (SI) with either Phaseolus vulgaris leucoagglutinin (PHA-L) or biotinylated dextran amine (BDA) and demonstrating the course and terminations of the axons that arise within the barrel fields. The method not only dramatically illustrates the previously described corticothalamic pathway to VPM but also demonstrates a strict topography in the cortical afferents to the thalamic reticular nucleus (RT). Cells supplying the RT projection are found below the barrels in layer IV. Connections to the posterior thalamus, on the other hand, have no discernible topography and are derived from cortical areas surrounding the barrels. Thus the outputs of these 'septal' areas return to the region from which they receive thalamic input. The corticocortical connections are also visible in the same material. Contralateral cortical connections arise from the cells of the septa between barrels. The projections to secondary somatosensory area (SII) are mirror images of the barrel pattern in SI with rather more overlap but nonetheless a recognisable topography.

Double anterograde tracing of outputs from adjacent "barrel columns" of rat somatosensory cortex. Neostriatal projection patterns and terminal ultrastructure.

The sensory input to the neostriatum from groups of cortical cells related to individual facial vibrissae has been investigated at both light- and electron-microscopic resolution. The purpose of the study was to establish the extent to which corticostriatal input maintains the anatomical coding of spatial information that is present in cortex. A double anterograde tracing method was used to identify the output projections from groups of adjacent neurons in different barrel columns, so that the anatomical relationships between two groups could be studied throughout their length. Adjacent whiskers are represented in adjoining cortical barrels and an examination of corticostriatal projections from these reveals two patterns of projection. In one, the anatomical topography is partially preserved; the barrels are represented in adjoining, discrete, areas of the somatosensory neostriatum. In the second projection pattern, the neostriatal innervation is diffuse and adjacent barrels are represented in overlapping regions of the neostriatum. Moreover, the fibres are thinner, have smaller boutons, and are present in both the ipsilateral and contralateral neostriatum. The two systems also enter the neostriatal neuropile separately. The discrete topographic system enters the adjacent neostriatum as collaterals which leave the descending corticofugal fibres at right angles, while the diffuse system enters directly from the corpus callosum at an acute angle. Examination of the neostriatal terminal fields by correlated light and electron microscopy, shows that characteristic axospinous terminals on spiny neurons are made by both groups of cortical fibres, although they differ in their size and morphology. It is concluded that at least two corticostriatal pathways arise from the barrel cortex. One connection maintains some of the anatomical code implicit in the barrel pattern of primary somatosensory cortex, but another, more diffuse, system is overlaid upon it which may carry different information from this complex area of cortex.

Accuracy of carotid duplex is laboratory specific and must be determined by internal audit.

OBJECTIVE: To assess the accuracy of carotid duplex in a single vascular laboratory at the prediction of an angiographic 70% internal carotid artery stenosis. DESIGN: A retrospective review of all patients who underwent both carotid duplex and angiography in a 1-year period at a vascular unit which participates in the ACST trial. METHODS: Peak systolic velocity was used as a primary end-point in carotid duplex examinations with a PSV > 130 cm/s used as an indication for angiographic assessment. Biplanar arch aortography and selective carotid catheterisation were performed as indicated and diameter reduction calculated by the ECST method. RESULTS: The sensitivity of 130 cm/s for the detection of a 70% stenosis was 96% and the specificity 67%. If a PSV of 250 cm/s were used the sensitivity would be only 37% and specificity 96%. CONCLUSIONS: Applying duplex criteria from one centre to another is inappropriate. Laboratory specific audit of duplex and angiography is essential before deciding to abandon preoperative angiography for carotid disease.